Wednesday, April 1, 2015

Give And Take

California is considering the adoption of a prescription drug formulary and a bill has been introduced into the Assembly directing the Division of Workers' Compensation to do so.

Assemblyman Henry Perea, D-Fresno, on Feb. 27 introduced AB 1124, on his own, rather than carrying the measure for a sponsor, according to his press secretary, Alicia Isaacs, in order to "start the conversation."

A formulary is essentially a list of approved drugs for which carriers would have to pay without much debate or review, if any.

The conversation had been started a couple of years ago, frankly, when the California Workers' Compensation Institute, among other research agencies, started noting the increasing burden that drugs have on the workers' compensation system in terms of costs, and the detriment to injured workers that were being given drugs for "off label" use - primarily opioid variants to control pain.

Bernardo de la Torre, president of the California Applicants' Attorneys Association, indicated to WorkCompCentral Monday that the organization isn't necessarily against a formulary, but that there must be alternative provisions in case a person can not tolerate a particular drug or if what is in the formulary is not effective.

He said a formulary should include all medications and drug therapies that are available for a covered medical condition. Additionally, CAAA believes a formulary that includes only generic drugs "constitutes an unreasonable restriction" on the treatment of injured workers, he said.

Finally, he said prescriptions for a formulary drug from a network provider should not be subject to utilization review and IMR, de la Torre said.

Inclusion of "all" medications and drug therapies for a given medical condition does not seem workable to me, but the other requests seem reasonable.
Abraham Verghese on the failed human component of medicine.

There are two extreme examples of drug formularies in existence now: Washington and Texas.

Washington is seen as a more conservative formulary and much more restrictive than the one adopted by Texas a few years ago.

Both have been instrumental in controlling pharmaceutical expenses and have resulted in fewer opioid consequences - largely because those drugs aren't authorized for much.

In the WorkCompCentral article, president of Voters Injured at Work, Jesse Ceniceros, was critical of the talk of a formulary adoption, characterizing the plan as another attempt at cutting benefits under the guise of controlling costs.

"Who's saving what? All they're doing is taking away," he said. "It continues year in and year out."

And frankly Ceniceros makes a good point - study after study has affirmed that different treatments, such as physical therapy and cognitive pain management adaptations, are as good if not better than a fistful of drugs.

But by and large workers' compensation does not pay for these alternatives, or does not pay adequately so physicians are loath to engage them.

Reimbursement rates for office visits, where bed side listening can occur and is often very effective (sometimes folks just need someone to "listen") are generally too low, if there's any reimbursement at all, so physicians don't practice this important part of the care delivery equation.

In California, chiropractic therapy is limited to 24 visits - an artificial number that was a compromise arrived at when there was huge abuse by a few bad apples in the chiropractic community. But certainly there are instances when paying for an adjustment is cheaper than paying for the aftermath of prescription drugs gone bad.

In other words, what has happened over time is that treatment alternatives have been constricted so that handing an injured worker a bottle of pills is the only reasonable option.

We certainly can't discount the financial incentives that drug manufacturers and their distributors wave in front of physicians either - these conflicts of interest exacerbate an already volatile situation.

But, as Abraham Verghese pointed out in his excellent TED talk that I blogged about some time ago, there is a medical ritual that is transformative to patient healing: listening and then examining. The message this conveys to the patient is, "I will always, always, always be there. I will see you through this. I will never abandon you. I will be with you through the end."

Workers' compensation on the other hand seems all about abandonment.

Imagine if workers' compensation actually communicated "I will always be there."

So here's the bottom line:

The debate over a drug formulary needs to include as discussion points exclusion of formulary prescriptions from utilization and independent medical reviews, and a review of alternative therapies that can take the place of drugs in the first instance with adequate reimbursement schedules to promote those alternatives.

Give and take. Don't just take.

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